Basic Information
| Provider Information | |||||||||
| NPI: | 1700971363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEHOLL | ||||||||
| FirstName: | J. | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 63314 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282633314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286961312 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1216 6TH AVE W | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287393301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286926262 | ||||||||
| FaxNumber: | 8286925858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 9700526 | NC | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2238261C | 01 | NC | MEDICARE PTAN | OTHER | 891049J | 05 | NC | MEDICAID |